Student Health Center
Medical History Form
STUDENT INFORMATION
Name:___________________________________________________________________
Today’s Date: __________________
Last
First
MI
Student ID#:____________________________________________________________________
International Student ___Yes ___No
Sex:___ M / ___F
Date of Birth:__________________________________________________
Age:___________
Home Address:_______________________________________________________________ _____________________________________
Street (Number & Street)
City/Town
State
Zip
School Address:____________________________________________________________________________________________________
Dorm & Room
SUMS Box
Phone
Cell Phone Number:________________________________________________ Home Number:__________________________________
Student Class: ___Freshman ___Sophomore ___Junior ___Senior ___Grad
Anticipated Graduation Date:__________________
EMERGENCY CONTACTS
Please list up to 3 people whom we can contact in case of an emergency (Include parents)
Name
Relationship
Cell Phone
Home Phone
e-mail address
ALLERGIES (List type and reaction if yes)
None Known
Yes:________________________________________________________________________________________________
List medication, latex, food, environmental substance, insect bite/sting, or other allergies and reaction
MEDICATIONS: Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs, etc.
Medication Name
Why you take it
Dose (e.g.
mg/pill)
How many times per day
FAMILY HISTORY
Have any of your immediate relatives had the following?
Diabetes
Tuberculosis
Kidney Disease
High Blood Pressure
Heart Disease/Stroke
Sudden Death Under the Age of 50 from Nontraumatic Cause
Thyroid disorder
Seizure Disorder
Cancer (specify type)
Specify:
Stomach or Intestinal Disease Specify:
Bleeding Disorder
Alcoholism
Tobacco use
Substance Abuse (Street Drug Use, including marijuana)
Mental Illness
Yes
No
Relationship
REVIEW OF SYMPTOMS: Please check any symptoms you currently have or have had in the past
Constitutional
___Recent fevers/sweats
___Unexplained weight loss/gain
___Unexplained fatigue/weakness
___ Been admitted to a hospital (include dates
with explanation below)
___ Under current medical treatment
Eyes
___ Change in vision
___ Other: ______________
Ears/Nose/Throat/Mouth
___ Difficulty hearing
___ Ringing in ears
___ Hay fever/allergies/congestion
___ Trouble swallowing
___ Ruptured/perforated eardrum
___ Sinus Infection
___ Ear Infection
___ Other:_________________
Cardiovascular
___ Chest pains/discomfort
___ Palpitations
___ Short of breath with exertion
___ Bleeding disorders
___ High/Low Blood Pressure
___ Rheumatic Fever
___ Other:_________________
Breast
___ Breast lump
___ Nipple discharge
___ Other:__________________
Respiratory
___ Cough/wheeze
___ Coughing up blood
___ Asthma
___ Shortness of Breath
___ Other:______________
Gastrointestinal
___ Heartburn/reflux
___ Blood in stool
___ Change in bowel movement
___ Nausea/vomiting/diarrhea
___ Pain in abdomen
___ Ulcer
___ Other:________________
Genitourinary
___ Painful/bloody urination
___ Leaking urine
___ Nighttime urination
___ Discharge: penis or vagina
___ Unusual vaginal bleeding
___ Concern with sexual functions
___ Urinary tract infection
___ Kidney Stones
___ Other:___________________
Musculoskeletal
___ Muscle/joint pain
___ Recent back pain
___ Fracture: Site___________
___ Neck Injury
___ Sprain/Strain
___ Other:___________________
Skin
___ Rash
___ New mole or change in mole
___ Other:_________________
Neurological/Psychiatry
___ Headaches
___ Memory loss
___ Fainting
___ Seizures
___ Head Injury
___ Depression
___ Schizophrenia
___ Anxiety/Stress
___ Sleep Problem
___ Other:___________________
Blood/Lymphatic
___ Unexplained lumps
___ Easy bruising/bleeding
___ Other:___________________
Endo
___ Cold/heat intolerance
___ Increase thirst/appetite
___ Diabetes
___ Eating disorder
___ Other:___________________
Infectious Diseases
___ Chickenpox
___ Tuberculosis (TB)
___ Mononucleosis (Mono)
___ HPV
___ Sexually Transmitted Disease
___ Meningitis
___ Cold sores or herpes
___ Hepatitis
___ Other:___________________
Surgery
___ Appendectomy
___ Tonsillectomy
___ Other:___________________
Female Menstrual History
___ Cramps
___ Excessive flow
___ Irregularity
___ Do you miss classes because of menses?
___ Have you received treatment for menstrual
disorder?
___ Other:________________________
Substance Use: Do you or have you ever used:
___ Tobacco
Type:__________________________
Amount per day:_________________
___ Alcohol
# Drinks per day:__________________
___ Marijuana
Amount per day__________________
___ Street drugs (cocaine, heroin, etc)
Type:______________________
Amount per day:_____________
___ Other_________________________
Please explain all positive answers (those with check marks) further:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
I hereby authorize the University of Detroit Mercy Student Health Center (UDM-SHC) staff to provide medical treatment and services to me as they deem
appropriate. This authorization will remain in effect as long as I am a student at University of Detroit Mercy. In the case of a minor (under 18) a parent or
legal guardian’s signature below permits the student to obtain health care in the absence of the guardian. Information obtained in care or on these forms may
be shared with the Dean of Students office, University of Detroit Mercy Counseling Staff and Athletic Training staff. I consent to the use or disclosure of my
protected health information by UDM-SHC to any person or organization for the purposes of carrying out treatment, obtaining payment or conducting
certain healthcare operations. Protected health information used or disclosed by UDM-SHC may include HIV/AIDS related information, psychiatric and
other mental health information, and drug and alcohol treatment information, as long as such information is used or disclosed in accordance with Michigan
and Federal law, which may require you to provide specific written authorization. I understand that this consent is effective for as long as UDM-SHC
maintains my protected health information, which is 7 years after my graduation date. When a health care worker is exposed to my blood or body fluids
through a needle stick, cut or splash to the eye or mouth, I agree to have my blood tested for blood-borne diseases to include Hepatitis B and C Virus and
Human Immunodeficiency Virus (AIDS). The information I have given is true and accurate to the best of my knowledge. By signing below, I understand
and acknowledge the following and give my consent as described above:
_____________________________________________ ___________________________________________ Date: _____________________
Signature of Student
and Parent (if student is under 18 years of age)